Status:
Ready to upload
Record number:
1588
Adverse Occurrence type:
MPHO Type:
Estimated frequency:
Rare - difficult to believe it could happen again.
Time to detection:
4 years
Alerting signals, symptoms, evidence of occurrence:
A family seeking to have treatment with donor sperm to have a genetically related sibling were provided with treatment using the sperm of a different sperm donor. In this case the sperm was frozen in 2007 and used in treatment in Feb 2011. Baby born Nov 2011 and immediately apparent was of a different ethnicity.
Demonstration of imputability or root cause:
Witnessing systems failure. Relaxed approach at donor bank reception leading to inconsistencies in labelling with either donors themselves or the andrologist writing on the sample pots, no witnessing step for the donor code allocation. More than one sample collected at a time with the random processing of samples (not undertaken in chronological order in relation to procurement). Inadequate standard operating procedures for witnessing, processing and freezing donor samples.
Groups audience:
References:
Reference attachment:
Suggest references:
HFEA. Adverse incidents in fertility clinics: lessons to learn, 2010-2013
Expert comments for publication:
This case illustrates the importance of thorough and acurate witnessing. No more than one sample should be collected at a time and samples should be processed in chronocological order in realtion to procurement. Tissue establishments providing a sperm donor recruitment service should have dedicated reception staff to meet donors to verify their identity. Tissue establishments should also have a robust appointment system in place to help manage workloads and ensure sufficient staff are avalable to run the service.